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Irish National Audit of Stroke Care (INASC) Professor Hannah McGee RCSI Professor Des O ’ Neill TCD Dr Frances Horgan RC

Irish National Audit of Stroke Care (INASC) Professor Hannah McGee RCSI Professor Des O ’ Neill TCD Dr Frances Horgan RCSI Dr Anne Hickey RCSI. INASC Overview Stroke – assembling the jigsaw Dr Frances Horgan. INASC. Stroke in Ireland. 3rd most common cause of death

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Irish National Audit of Stroke Care (INASC) Professor Hannah McGee RCSI Professor Des O ’ Neill TCD Dr Frances Horgan RC

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  1. Irish National Audit of Stroke Care (INASC)Professor Hannah McGee RCSIProfessor Des O’Neill TCDDr Frances Horgan RCSIDr Anne Hickey RCSI

  2. INASC OverviewStroke – assembling the jigsawDr Frances Horgan INASC

  3. Stroke in Ireland • 3rd most common cause of death • Leading cause of acquired major disability • Stroke - a singular and complex illness • Major concerns over adequacy of services but very little data available • Aims of this project • to conduct a national audit of stroke care across the trajectory of care in hospital and the community in the Republic of Ireland Council on Stroke, 2001

  4. First comprehensive audit

  5. INASC PROJECT: Six StudiesMarch 2006-September 2007 • HOSPITAL • - Organisational audit - 37 hospitals………. √ • Clinical (chart) audit - 2570 charts………. √ • [based on UK Sentinel audit system] • COMMUNITY • GP Survey - 204 GPs……..………………. √ • AHP & PHN survey…75 professionals….. √ • Patient & carer survey…139 patients, 72 carers…√ • Nursing home survey…60 homes…….… √

  6. Hospital Audit - Methods • Organisational Audit: • Aim - Audit of the organisational aspects of stroke care in acute hospitals with regard to resources for organised stroke care • Structured face-to-face interview with Management Team • Clinical Audit: • Aim: Audit of Stroke Care - review clinical case notes (2,570) for representative sample of patients • Charts identified for Jan-March 2005 and July-Sept 2005 (HIPE ICD10 I61 I63 I64)

  7. Emergency and acute hospital care • Only one Irish hospital had a stroke unit • Thrombolysis almost non-existent - 1% • Swallow screening - available 5 sites • 16% of hospitals had TIA clinics

  8. Staffing and acute hospital care • One third of hospitals had lead consultant for stroke care (only 5 protected time) • 5 clinical nurse specialists • 2 clinical specialist therapists • Availability of MDT limited • Clinical psychology almost non-existent

  9. Acute hospital care Access to rehabilitation • 35% of hospitals had access to on-site rehabilitation • Limited access to rehabilitation for younger stroke patients • Stroke specific MDT meetings in only 22% hospitals • 22% had documented rehabilitation goals (76% UK06)

  10. Who gets stroke? UK 06 - Men 52% Women47% • 19% < 65 years (17%) • 92% living at home at the time of the stroke • 73% independent in activities of daily living (ADL) pre-stroke • On discharge… • 56% discharged home • 15% newly institutionalised (13%) • Only 28% independent in ADL at discharge(39%)

  11. Co-morbidity Profile

  12. Acute hospital - diagnostics • 71% admitted on day of stroke, 5% within 2 hours of stroke (UK 39%) • 30% did not have routine access to CT within 48hr of stroke and only 41% emergency MR scanning • Time from stroke to scan mean 2.6 days, median* 1 (1 day* UK06) • INASC 4% scanned within 3 hours (9% UK06)

  13. Standards within 72 hours UK 06 • SLT swallow screen 26% (66%) • SLT swallow assessment 25% (67%) • Physiotherapy assessment 43% (71%) • Nutrition assessment 81% (93%) • Aspirin within 48 hours 43% (67%)

  14. Standards within 7 days UK 06 • SLT communication assessment 29% (69%) • OT assessment 22% (68%) • Continence plan 13% (54%)

  15. INASC - Onset/Hospital Stay

  16. Communication patients and carers UK 06 • Discussion stroke diagnosis 22% (69%) • Discussion stroke prognosis 18% (59%) • Assessment of carers needs 24% (68%) • Skills taught to carers 12% (71%) • 7% Irish patients had a home visit (63%) • Only 4 hospitals had a hospital/community liaison person

  17. Medications

  18. Acute hospital care - secondary prevention UK 06 • 51% cause stroke identified/documented (73%) • Smoking cessation 9% (79%) • Reduce alcohol 7% (80%) • Exercise 8% (41%) • Diet advice 14% (42%) • 67% Blood cholesterol documented (NA)

  19. Discharge from hospital & follow-up • GP informed of patient’s discharge • 56% of GPs notified on day of discharge • 24% of discharge summaries indicated functional status • 35% had carotid imaging within 3 months

  20. Audits and improvement - INASC vs. Sentinel Rounds UK

  21. INASC Main findings: community stroke managementDr Anne Hickey

  22. Community Surveys: Methods • National GP survey: • Randomly selected (n=204: 46% response), postal survey • Allied health professional (AHP) & public health nurse (PHN) survey (3 phases): • N=75 interviews/postal survey involving Local Health Office managers, AHP/PHN managers and frontline staff across 8 disciplines • Patient & carer survey: • Interviews with 139 (55% response) patients and 72 carers • Nursing home survey: • Interviews with proprietor/manager in 60 nursing homes (20 Dublin, 40 outside Dublin) and residents with stroke

  23. GP Survey - Stroke Management • Information letter at discharge focused almost entirely on diagnosis; little information on functional ability, rehabilitation or community services organised • Staff shortages most significant barrier to rehabilitation - lack of OT, SLT, physiotherapy and home help • GP stroke patients residing in nursing homes - c. 25%

  24. AHP/PHN Survey - Stroke Management/Service Provision • PLANNING: • No stroke statistics/registers - Absence of information on prevalence of stroke in community makes planning for comprehensive community-based stroke service very difficult • DISCHARGE: • Communication at discharge absent, delayed or limited • Equipment / support often not in place at discharge • TEAMWORK: • Separate notes; few team meetings • Multidisciplinary service, not operating as multidisciplinary team • Access to dietetics, social work & psychology largely non-existent • LIMITS: • Services age-related (younger have limited access) • Limited input to nursing homes

  25. AHP/PHN Survey - Conclusions • Inequitable access to rehabilitation - no programmes in some areas • Community AHP staffing levels do not reflect availability for stroke-related service provision • Need for key worker to ensure streamlined services • Current staffing levels and employment ceilings restrict service development - complete absence of some disciplines in some areas (notably social work, speech & language therapy, dietetics, psychology)

  26. Patient/carer perspectives on hospital discharge • Inconsistent, haphazard discharge planning: • 75% no family conference prior to discharge • 67% no contact name after discharge • 33% necessary services not in place on discharge • 34% no information on purpose of medication, 70% not informed of potential medication side-effects

  27. Patient/carer perspectives on community stroke care • Poor community rehabilitation • 50%+ not getting sufficient mobility treatment • Approx. 50% not getting sufficient SLT treatment • 75% no support with emotional difficulties • Less likely to receive services if under 65 years

  28. Stroke carers • Need for information and support about diagnosis, prognosis and post-hospital care • Carer expected to become ‘expert’ once patient came home • Need for ‘key worker’ to provide contact if needed • One in 10 carers classified as ‘at risk’ of health problems; all women, predominantly over 65

  29. Nursing Home Residents and Stroke N= 570 residents with stroke: 83% > 75yrs; 2% < 65yrs

  30. Stroke Resident Impairments

  31. Nursing Homes: Access to Services • Access to GP ‘very good’ • Access to rehabilitation professionals-’POOR’ • Stroke patients described as ‘discharged from active rehabilitation services’ - some access to physiotherapy - very limited access to SLT, OT, dietician, social work; no access to psychology • Many challenges appear similar to those of nursing home residents generally

  32. Preventing and Managing Stroke in the Community • Little or no organised system of care for the management of stroke in the community • Little systematic or organised primary prevention of stroke • Lack of awareness evident in other Irish research • Major awareness and education campaign needed (rapid response essential): • Public and those working with public • Primary care professionals • Hospital and rehabilitation professionals

  33. Primary prevention of stroke • Barriers to implementation of stroke primary prevention strategies in primary care: • Inadequate staffing • Time pressures • Lack of designated funding • Lack of screening protocols • Lack of risk factor management protocols

  34. Potential for Stroke Prevention and Screening in General Practice • Heartwatch (heart disease management) GP practices much more likely to have: • Registers of patients with hypertension • Registers of patients with diabetes • Registers of patients with atrial fibrillation • Registers of patients with stroke • Regular practice audits • Potential to expand to Cardiovascular Watch, to include key stroke-related variables (e.g., screening for atrial fibrillation)

  35. INASC Implications of findings for stroke services in IrelandProfessor Desmond O’Neill

  36. ‘After I got home, there should have been someone to help from the start’. (Patient) ‘No one seemed to know who was looking after him; there was no follow-up, and very little support was available’. (Carer) ‘I was only 52 and had my own business. I miss the contact with work colleagues and can go for weeks without seeing anyone’. (Patient) ‘A contact person would have been nice, someone to talk to’. (Patient)

  37. INASC Summary • Allows quality of care comparisons against professional guidelines and neighbouring jurisdiction (UK National Sentinel Audit) • Provides comprehensive profile of stroke care across primary and secondary prevention, acute treatment, rehabilitation and longer-term care • Enables evidence-based planning and evaluation of strategies to improve service delivery

  38. INASC Implications • National strategy for stroke • Regional governance, implementation of stroke care • Stroke register • Primary prevention - supportive structures • Reconfiguration hospital services • Urgent development STROKE UNITS with appropriate services and staff • Rehabilitation at all stages of care

  39. Implications… • Systems for sharing information and follow-up • Ongoing support and community rehab • Information on stroke patients and carers • Major developments staffing and specialist training for all disciplines • Equitable needs based access to care • Public awareness programmes • Transportation • Repeat audit cycle

  40. Acknowledgments Hospital staff; physicians, management team, HIPE staff, Medical Records. Chart auditors ESRI Health Policy Unit National Hospitals Office Sentinel team UK - Dr Tony Rudd and Mrs Alex Hoffman Stroke patients and their carers Nursing home staff Community PHNs AHPs, AHP Managers and Frontline staff, LHOMs General Practitioners Professional organisational submissions Ms Imelda Noone and Ms Aisling Creed

  41. INASC Project Steering Group • Professor Hannah McGee - Psychology RCSI (Co-PI) • Professor Des O’Neill - Gerontology TCD (Co-PI) • Dr Frances Horgan - Physiotherapy RCSI (Project Manager/Lead Hospital audit) • Dr Anne Hickey - Psychology RCSI (Lead Community Projects) • Professor Seamus Cowman - Nursing RCSI • Professor David Whitford - General Practice RCSI • Dr Emer Shelley - Epidemiology RCSI • Dr Sean Murphy - Midland Regional Hospital Mullingar • Professor Miriam Wiley - Economic & Social Research Institute • INASC Project Research Staff • Research Staff at the Division of Population Health Sciences (Psychology), RCSI: Ms Karen Galligan, Ms Helen Corrigan, Ms Maeve Royston, Ms Maeve Proctor, Ms Oonagh Mullan, Ms Abigail Henderick, Ms Anna-May Fitzgerald, Ms Philippa Coughlan, Dr Bernadette O’Sullivan, Ms Claire Donnellan and Dr Maja Barker

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